Basic Information
| Provider Information | |||||||||
| NPI: | 1831288471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALKER | ||||||||
| FirstName: | REBECCA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 99213 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761990213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6828854471 | ||||||||
| FaxNumber: | 6828853939 | ||||||||
| Practice Location | |||||||||
| Address1: | 6316 PRECINCT LINE RD | ||||||||
| Address2: | |||||||||
| City: | HURST | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760542766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8176052504 | ||||||||
| FaxNumber: | 8176052505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | E3796 | TX | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 125290007 | 05 | TX | MEDICAID | 0003GS | 01 | TX | BCBSTX GRP PIN | OTHER | 124068 | 01 | TX | SUPERIOR PIN | OTHER | 1416131 | 01 | TX | FIRSTHEALTH PIN | OTHER | 125290004 | 05 | TX | MEDICAID | 170994101 | 05 | TX | MEDICAID | 8Z1880 | 01 | TX | BCBSTX IND PIN | OTHER | 163314101 | 05 | TX | MEDICAID | 1124098447 | 01 | GRP NPI NUMBER | OTHER | 125290008 | 05 | TX | MEDICAID | 4057626 | 01 | TX | AETNA PIN | OTHER | 080626701 | 05 | TX | MEDICAID |